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Continuing and Distance Education for the Advanced 

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 Sunday, December 26, 2010

“Recovering A-NEW”  Oval: R

A Culturally Competent Cognitive/Behavioral Treatment Model

(Ground Zero: The Urban War-Zone)

Trauma/Addiction in Therapy

When we reflect on those variables that factor into the complexity of Post-Traumatic Stress Disorder (PTSD), anyone who has work in mental health know that substance abuse is one of the cardinal features of PTSD. The role of abuse may appear to be obvious, however, despite the prevalence and clinical significance of substance disorders in individuals with PTSD, relatively little is actually known about the comorbidity of these disorders. The majority of published papers on this topic are based on clinical experience and/or theory, with little empirical research to support them1. Within the empirical literature, studies have varied widely in their approach to examining this problem.  Moreover, many studies have examined substance use only as a secondary outcome within a larger analysis of trauma, PTSD, and related disorders. With these caveats in mind, this issue of the PTSD Research Quarterly provides an overview of the research literature on PTSD and substance abuse (PTSD/SA) comorbidity. In attempting to better understand this complex literature, the review is organized using the following heuristic framework: (a) substance abuse problems in individuals with PTSD, (b) trauma and PTSD symptoms in substance abuse clients, (c) "self-medication" and prediction of substance use based on pre-, peri-, and post-trauma factors, (d) moderating variables, and (e) symptom overlap. Results of studies using both clinical and epidemiologic samples are reviewed and compared. Methodologic issues are addressed and directions for future research are discussed.

            Lifetime prevalence rates of alcohol abuse/dependence among men and women with PTSD are approximately 52% and 28%, respectively, while lifetime prevalence rates for drug abuse/dependence are 35% and 27%, respectively. Such comorbid disorders are not only complicated treatment but in some might also exacerbate PTSD itself. In addition, a number of legal substances such as nicotine, caffeine, and sympathomimetrics, e.g., nasal decongestants, may interfere with treatment and, therefore, should be carefully assessed with all PTSD clients. In many cases, if significant chemical abuse/dependency is present, it is recommended one should address the substance abuse before PTSD treatment is initiated.  

Comorbidity of Substance Disorders in PTSD
            Client Studies of individuals seeking treatment for PTSD have consistently found a high prevalence of drug and/or alcohol abuse. Keane went on to explain, in his oft-cited paper, Keane et al. (1988) summarized results of previous studies as well as their own data by suggesting that 60-80% of treatment-seeking Vietnam combat veterans with PTSD, as its counterpart, the urban War Zone, also met criteria for current alcohol and/or drug abuse. In a subsequent well controlled study, Boudewyns et al. (1991) reported that 91% of their inclient PTSD sample met lifetime criteria for a substance use disorder. In the largest and most recent study of 5,338 veterans seeking treatment within the Department of Veterans Affairs specialized out patient client PTSD programs, Fontana et al. (1995) reported that 44% met criteria for alcohol abuse/dependence and 22% for drug abuse/dependence. These somewhat lower prevalence estimates may reflect both outclient versus inclient presentation as well as differences in assessment methodologies.
The high level of comorbidity may be influenced in part by selection bias, as problems with substance use may increase the likelihood of treatment seeking in general. This argument is supported by Helzer et al/s (1987) epidemiologic survey data from civilian PTSD, which suggested only a small increase in risk for substance abuse. In contrast, Kessler et al. (1995) reported higher comorbidity prevalence estimates in a representative community sample of 5,877 persons.

            Using the DIS, they found that 52% of men and 28% of women with PTSD also met lifetime criteria for alcohol abuse or dependence. For drug abuse, the numbers were 35% and 27%, respectively. These rates reflected significant increase in risk for comorbid SA over individuals from the same sample who did not have PTSD. Despite these elevated prevalence estimates, community-based estimates among those of combat veterans strongly correlate with those who live at Ground Zero, in the urban war zone, are higher still. For example, using the NVVRS epidemiologic data, Kulkaetal.(1990) reported that 73% of Vietnam veterans with PTSD met lifetime criteria for alcohol abuse or dependence. In sum, data from both epidemiologic and clinical studies support the increased prevalence of substance use disorders associated with PTSD. Although the epidemiologic data on civilian trauma are less clear, several studies of civilian trauma in clinical samples (e.g., sexual abuse victims) suggest increased prevalence of
substance abuse (see recent review in Stewart, 1996).

Prevalence of Trauma and PTSD in Substance
            Abuse Clients alternative paradigm for examining comorbidity has been to study trauma exposure and PTSD symptoms in individuals engaged in substance abuse treatment. These studies have tended to focus on civilian trauma, thus making comparison with studies of combat-related PTSD difficult. For example, Brown et al. (1995) studied 84 men and women in an inclient substance abuse treatment program and found that 43% of women and 12% of men met criteria for PTSD based on the civilian version of the Mississippi scale. Women reported an average of 2.1 traumas in their lifetime compared to an average of I.I for men, with a greater occurrence of sexual abuse, physical abuse, and rape. In a similar study with a more urban and impoverished sample of women drug users, Fullilove et al. (1993) reported a mean of five traumatic experiences and a PTSD prevalence of 59%% based on SCID diagnoses. Avoiding some of the biases in clinic-based research. Cottier et al. (1992) analyzed data from 2,263 respondents participating in a large epidemiologic survey of substance use and psychiatric illness in the general population. The Diagnostic Interview Schedule was used to assess both substance use and PTSD. Substance users reported having experienced more traumatic events than non-users. Opiate and cocaine users reported the greatest prevalence of traumas, and 19% of these users met criteria for PTSD. Interestingly, regression analyses suggested that cocaine/opiate use among women was a risk factor for PTSD independent of trauma exposure. Although PTSD prevalence estimates were much lower than those reported in treatment-seeking samples, they significantly exceeded estimates among non-substance users in terms of both trauma exposure and PTSD. Thus, data from both clinical and epidemiologic sources support the high prevalence of PTSD comorbidity among substance users.

            The comparison of these two approaches to comorbidity begs the question of primacy of one disorder over the other. Many theories and studies of substance abuse comorbidity in PTSD have assumed, either implicitly or explicitly, that PTSD is the primary disorder and that substance use reflects a "self-medication" of symptoms. The model is based loosely on Khantzian's (1985) notion that psychoactive drugs serve to reduce negative effect, and that this reduction negatively reinforces continued substance use. Models of alcohol's reinforcing properties via stress reduction, such as Conger's (1956) tension reduction hypothesis and the more sophisticated stress response dampening model (Levenson et. al. 1980), are also consistent with this view.

            A number of studies have yielded data that bear either directly or indirectly on the self-medication hypothesis. Two studies examining age of onset in Vietnam combat veterans (Davidsonetal., 1990; Bremner et al. 1996) also, fall within the parameters of the age group suggests that PTSD and substance abuse have concurrent onset. In addition, data from Bremner and colleagues (1996) suggest that PTSD symptoms and substance abuse not only emerged simultaneously but followed a relatively parallel course over time. Data from Cottier et al.’s  (1992) community African-American and Latino youth (the mean age is 19.5), coming out of the Urban War Zone, used study suggest that drug and alcohol abuse symptoms developed prior to PTSD symptoms; unfortunately, age at traumatic event was not accounted for. In contrast, Kessler et al.'s (1995) epidemiologic data suggest that the occurrence of trauma related to subsequent PTSD development was significantly more likely to precede substance abuse, particularly for women. Differences in sample characteristics, nature of trauma, and assessment methodologies are all likely contributors to these varying results.

Other Researchers (Principle Investigators) have provided data on self-medication by using multiple regression models in an effort to identify trauma-related and PTSD-related predictors of substance abuse. Green et al. (1989) focused on the role of trauma type in predicting PTSD and comorbidity disorders in 1968 Vietnam combat veterans. They found that exposure to grotesque death (e.g., mutilation) and/or graves registration was predictive of alcohol abuse; the presence of a pre-war psychiatric condition also contributed significantly and independently to alcohol abuse comorbidity. McFall and colleagues (1992) examined substance abuse patterns in a sample of 108 combat veterans and 151 non-combat controls. Results of regression equations indicated that drug and alcohol abuse was associated with both PTSD severity and combat-related variables. Interestingly, specific PTSD symptom patterns were predictive of substance use patterns; elevated arousal symptoms were associated with alcohol problems, whereas avoidance/numbing was associated with drug abuse.

            Two epidemiologic studies of veterans have also evaluated the contribution of trauma and PTSD-related variables to substance use. Reifman and Windle (1996) used data from the CDC Vietnam experience study of 2,490 Army veterans. Drug use while in the Army was the single best predictor of recent drug use. Combat exposure also predicted recent drug use but, contrary to predictions, this relationship was not mediated by PTSD. The authors interpret this negative finding as a failure to support the self-medication hypothesis. Interestingly, Boscarino (1995) used the same data set in an examination of the role of social support in PTSD but failed to find a relationship between combat exposure and drug use. In his analyses, premorbid factors such as childhood delinquency emerged as the best predictors of recent drug and alcohol use.

Potential Moderators of Self-Medication
            The extent to which the self-medication model is useful in explaining comorbidity may be moderated by individual differences, including differences in sociodemographics, treatment history, and family history for substance use and anxiety disorders. Moreover, attitudes and beliefs about drug effects on emotional regulation may be a significant moderator. For example, investigators examining cognitive factors in alcohol use demonstrated that belief in alcohol's tension reducing effect was the best predictor of problem drinking and treatment adherence (Brown, 1985). Cognitive factors such as attention are also thought to play a role in alcohol's effects. Moreover, Steele and Josephs (1988) demonstrated that alcohol decreased anxiety related to an impending stressor when attention was focused on a distracting activity; in contrast, alcohol increased anxiety in the absence of distraction. Such attentional effects may account in part for the alcohol-induced exacerbation in distress and intrusion symptoms often observed in clients with PTSD.

Symptom Overlap
            Additional factors related to commonalities between the two disorders must also be considered in any comprehensive model. First, intoxication and withdrawal states can mimic arousal symptoms of PTSD. In support of this argument, Saladin et al. (1995) found increased hyperarousal symptoms in the early stage of abstinence in PTSD alcohol abusers as compared to individuals with PTSD and comorbid cocaine abuse (see also McFall et al. 1992). Second, a large literature has documented coping skills deficits and a tendency to use avoidant coping among substance abusers. This avoidant coping style, particularly vis-a-vis traumatic material, is also characteristic of PTSD. Third, a common biologic substrate involving catecholamine dysregulation and locus ceruleus activation may contribute to both disorders independently (Kosten & Krystal, 1988).
            These and other areas of overlap must be considered in accounting for rates and mechanisms of comorbidity. Future Directions Future research must be both specific and comprehensive if we are to advance our understanding of PTSD/SA comorbidity. Laboratory studies using drug/alcohol challenge paradigms and self-administration paradigms will increase our knowledge of the parameters of self-medication (see Stewart, 1996). Studies based on cue conditioning models of symptom and substance use interaction, including both laboratory cue reactivity studies and field studies using "on-line" monitoring of symptoms, urges, and substance use, will also contribute to this effort. At the same time, large studies incorporating multiple predictors of PTSD and SA will account for more covariance in these two disorders. However, studies that do not adequately control for specific features of the population, the trauma, the PTSD, or the substance use patterns are likely to contribute little new information. Finally, prospective studies of individuals at risk for trauma (e.g., military personnel, gang members, young substance users and the high risk urban population of South Central Los Angeles) will assist in further elucidating this complex relationship.

Women with Substance abuse Disorder/PTSD
            There is a critical need for the integrated models that address the comorbidity of the two disorders of PTSD and Substance Abuse Disorders. Among women in particularly because of the significance of the two disorders exacerbating one another, e.g., avoidance, dissociation and having elevated anxiety. It appears that the use of illicit and/or licit chemical “numb” the individual from dealing with such feelings that is associated with these stressors. The need is for the clinical presentation and treatment needs to be met. The treatment educates the client(s) about the two disorders, promotes self-control skills to manage overwhelming affects, teaches functional behaviors that may have deteriorated as a result of the disorders, and provides relapse prevention training.

             One such model is a Cognitive-Behavioral Therapy Group that provides the far mention techniques. This draws on educational principles to make it accessible for this difficult treat population; the aid of visual imagery, education of the clients/client role, teaching generalization, emphasis on structured treatment, testing of acquired knowledge of CBT, affectively engaging themes and materials, and enchantment of memory devices.

            Substance Abuse Disorder (SUD) and posttraumatic stress disorder (PTSD) co-occur at a relatively high rate, often portending a more severe course than would occur with either disorder alone (Brady, Killeen. Saladin, Dansky, & Becker, 1994; Brown, Recupero, & Stout, 1995: Miller, Downs, & Testa, 1993; Najavits et al., 1995). Estimates of substance abuse or dependence in PTSD clients range from 16% to 8070 (Breslau & Davis, 1987), depending on the clinical population surveyed. In a general population study of young urban adults (the Ground Zero Urban War Zone), the rate of substance use disorders was 43-0 among those diagnosed with PTSD, compared to 25% for those without (PTSD) (Breslau, David, Atidreski & Peterson, 1991). A study of 363 opioid addicts found that 31% had histories of childhood trauma: this subgroup showed more impaired psychological, medical, employment, family and social functioning than opioid addicts without histories of childhood trauma (Rounsaville, Weissman, Wilber, & Kleber, 1982). While these data arc suggestive of a strong comorbidity between the two disorders, the methodological limitations of the various studies must also be considered. For example, the study by Breslau and Davis ( 1987) used DSM-lll diagnoses and studied only a male Vietnam veteran in client sample. The study by Breslau et al. (1991) used the Diagnostic Interview Schedule with a sample of middle class members of a health maintenance organization. The sample of the Rounsaville et al. (1982) study was mostly male.

            The relationship between the two disorders is complex. Moreover, the presence of either disorder can increase the risk of developing the other disorder.  A recent report (Cottier, Compton, Mager, Spilznagel & Janca. 1992) from the St. Louis Epidemiological Catchment Area Study showed that substance users had a higher likelihood of traumatic events compared to non-users, and that the substance use typically preceded the PTSD. In addition, certain drugs (cocaine and opioids) showed a higher association with trauma and the diagnosis of PTSD than did other drugs such as marijuana. Even a family history of substance use problems is a significant risk factor for exposure to traumatic events (Breslau et aL, 1991). Conversely, the presence of trauma has also been associated with the development of SUD (O'Donohue & Elliott, 1992; Rounsaville el. al., 1982); this has been termed the "traumatogenicity" theory of substance use disorders (Berk, Black, Locastro, & Wickis, 1989). The relationship between the two disorders also appears to be more enduring than, for example, other Axis I disorders (such as mood or anxiety syndromes) in which attaining abstinence from substances is strongly associated with a reduction in psychiatric symptoms ( Brown & Schuckit, 1988). In addition, PTSD and SUD have consistently been found to be comorbid regardless of the nature of the trauma (Keane & Wolfe, 1990).

            Henceforth, the vast majority of work on this dually diagnosed population has focused on male combat veterans whose SUD developed or worsened after exposure to the traumas of war. Research on females with the two disorders has been minimal, despite the fact that both Breslau et. al. (1991) and Kessler et al. (1994) found that women were twice as likely as men to have PTSD. Moreover, it has become increasingly clear that male combat clients and female trauma victims (typically exposed to physical or sexual assault) may represent different subtypes of PTSD (Herman, 1992: O'Donohue  Eliott, 1992). Women trauma survivors arc described as having different fears from combat veterans and more self-blame, suicide attempts, sexual dysfunction, and revictimization (0'Donohue & Elliott, 1992). In a major epidemiological study Cottier
et al. (1992) found that for people with SUD, combat events were the least likely traumatic events, whereby physical assaults were the most likely. After all other variables were controlled, female gender and use of cocaine or opioids predicted a diagnosis of PTSD (among subjects exposed to traumatic events) while age, race, depression and antisocial personality disorder did not (Cottier et. aL, 1992). In another recent study (Miller et aL, 1993), 70% of a sample of 98 women in treatment for alcoholism reported childhood sexual abuse: these clients had significantly higher rates of such abuse than women in the same treatment setting without alcohol problems and women in a household sample. In general, women are at relatively high risk for trauma, with lifetime estimates of sexual assault at 25% to 50% from samples taken within the community, and a childhood history of sexual abuse in approximately 50% of female in clients (Foy, 1992). Females are at higher risk for child sexual abuse, rape, and spouse battering than
are males (Foy, 1992; O'Donohue & Elliolt, 1992).

            It has been note in recent years, there has been an increasing literature on the treatment of clients with SUD and co-existing psychiatric illness. Most authors have suggested the importance of addressing both disorders and their interaction (Meyer, 1986: Mirin & Weiss, 1991). However, there has been relatively little empirical research that has specifically addressed the treatment of women with co-existing SUD/PTSD. The use of cognitive-behavioral therapy (CBT) for comorbid SUD/PTSD is suggested for several reasons. First, in both SUD and PTSD, and certainly in their combination, clients are often reported to be overwhelmed by negative effects such as extreme guilt, anxiety, shame, self-blame, depression, suicidal feelings, and dissociation (Beck, Wright, Newman, & Liese. 1993: Chu, 1991; Herman, 1992). CBT is often used to teach the client to self-manage affects, either as an end in itself or so that exploration using more psychodynamic, exploratory therapies can proceed without the client's regression. CBT self-control strategies such as impulse control programs, re-attribution, grounding, problem solving, cognitive restructuring, anger management, and cue exposure are commonly used with both disorders (Beck et al., 1993; Foa, Stekeice, & Rothbaum, 1989; Mackay, Donovan, & Marian, 1991; Marlatt & Ordon, 1985). Second, CBT teaches functional behaviors that may never have developed or may have deteriorated due to drug use and the sequelae of trauma. These include relationship skills (assertiveness, negotiation, asking for help, active listening); problem solving; self-nurturing techniques (such as coping self-talk, positive self-statements); and adaptive lifestyle activities (such as daily activity planning, relaxation training). Third, CBT offers explicit training in relapse prevention. Since clients with substance use disorders commonly have high relapse rates, such training is essential. Relapse prevention techniques are also directly modifiable for other Axis I disorders (Hollon & Najavils, 1988) and are likely to be relevant to PTSD (e.g., the need to prevent relapse to dissociative symptoms and self-harm behaviors). Specific techniques, for example, include the development of a hierarchy of situations that trigger relapse and in vivo behavioral exercises (o rehearse coping strategies. Thus far, there has been extremely limited empirical testing of CBT for PTSD populations (Solomon, Gerrily, & Muff. 1992).

Problems that Occur with Alcohol use and PTSD
            PTSD does not automatically cause problems with alcohol use: many people with PTSD do not have problems with alcohol use. However, PTSD and alcohol can be serious trouble for the trauma survivor and for the family, for three scientifically documented reasons: PTSD and alcohol problems often occur together, that is most apparent in the urban community that is Ground Zero war zone. People with PTSD are more likely than others of similar background to have alcohol use disorders both before and after being diagnosed with PTSD, and people with alcohol use disorders often also have PTSD2. Veterans over the age of 65 with PTSD are at increased risk for attempted suicide if they experience problematic alcohol use or depression.

            Alcohol problems often lead to trauma and also disrupt relationships. Persons with alcohol use disorders are more likely than others of similar background to experience psychological trauma and to have problems with conflict and intimacy in relationships. Women exposed to trauma show an increased risk for an alcohol use disorder even if they are not experiencing PTSD. Women with problematic alcohol use are more likely than other women to have been sexually abused at some point in their life. Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women. Problematic alcohol use is associated with a chaotic lifestyle, which reduces family emotional closeness, increases family conflict, and reduces parenting abilities.

            PTSD symptoms often are worsened by alcohol use. Although alcohol can provide a feeling of distraction and relief, it also reduces the ability to concentrate, to enjoy life and be productive, to sleep restfully, and to cope with trauma memories and stress. Alcohol use and intoxication also increases emotional numbing, social isolation, anger and irritability, depression, and the feeling of needing to be on guard (hypervigilance). Alcohol use disorders reduce the effectiveness of PTSD treatment. War veterans diagnosed with PTSD and alcohol use tend to be binge drinkers. Binges may be the result of re-experiencing memories or reminders of trauma.  Many individuals with PTSD experience sleep disturbances (trouble falling asleep or waking up after they fall asleep). When a person with PTSD experiences sleep disturbances, using alcohol as a way to "self-medicate" becomes a "two edged sword": it may help with one sleep-
related problem but exacerbate another. Alcohol use may decrease the severity and the number of frightening nightmares commonly experienced in PTSD, but may continue the cycle of avoidance found in PTSD. When a person withdraws from alcohol, nightmares often increase.

            With final note to this paradox, individuals with a combination of PTSD and alcohol use problems often have additional mental or physical health problems. As many as 10-50% of adults with alcohol use disorders and PTSD also have other one or more of the following serious disorders: anxiety disorders (such as panic attacks, phobias, incapacitating worry or compulsions) mood disorders (such as major depression or dysthymic disorder) disruptive behavior disorders (such as attention deficit or antisocial personality disorder) addictive disorders (such as addiction or abuse of street or prescription drugs) chronic physical illness (such as diabetes, heart disease, or liver disease) chronic physical pain, both due to physical injury/illness and with no clear
physical cause. As a result, alcohol use problems often must be addressed in PTSD treatment. When alcohol use is (or has been) a problem in addition to PTSD, it is best to seek treatment from a PTSD specialist who also has expertise in treating alcohol (addictive) disorders. In any PTSD treatment, several precautions related to alcohol use and alcohol disorders are advised: When the clinicians initiated the initial interview and questionnaire assessment should include questions that sensitively and thoroughly identify patterns of past and current alcohol and drug use. Treatment planning should include a discussion between the professional and the client about the possible effects of alcohol use problems on PTSD, sleep, anger and irritability, anxiety, depression, and work or relationship difficulties. Treatment should include education, therapy, and support groups that help the client address alcohol use problems in a manner acceptable to the client. Treatment for PTSD and alcohol use problems should be designed as a single consistent plan that addresses both sources of difficulty together. Although there may be separate meetings or clinicians devoted primarily to PTSD or to alcohol problems, PTSD issues should be included in alcohol treatment, and alcohol use ("addiction" or "sobriety") issues should be included in PTSD treatment. Relapse prevention must prepare the newly sober individual to cope with PTSD symptoms, which often seem to worsen or become more pronounced with abstinence.

            The use of a group format could be quite useful for SUD/PTSD clients, given the importance of social support for these disorders (Herman. 1992). Treatment of both SUD and PTSD requires significant attention to validation of experience, shame reduction, and normalization because of strong feelings of self-blame that often accompany the disorders (Beck et aL. 1993: Herman. 1992). Also, group treatment can craft larger segments of the population due to its lower cost, and is a standard modality of in client and out client psychosocial treatments. Group treatment is also a well-established modality for cognitive-behavioral intervention and has been empirically shown to be effective when compared with individual CBT treatment (Najavits & Garber, 1989).

In conclusion
            The development of a CBT treatment manual gender specific for female clients with SUD/PTSD until NOW has not yet occurred that addressed not only the cultural needs of our population but the verifiable evidence-based empirical data that is specific gendered based. However, there is some evidence for the efficacy of CBT for SUD (Hollon & Najavits, 1988; Woody, McLellan, Luborsky, & O'Brien, 1990). It is to be noted that Recovering A-NEW A Culturally Competent Cognitive/Behavioral Treatment Model developed for, i.e. South Central Los Angeles Spa-6 (Ground Zero: Urban War Zone) not only addresses the gender specific of women SUD/PTSD issues simultaneously, but creates notable change and self awareness that foster a greater quality of life. Indeed, "relapse prevention," which derives from CBT, has a relatively long-standing tradition within SUD treatment programs (Beck et aL. 1993: Mackay et al., 1991). The use of CBT with PTSD clients has been documented for in client females (Orzack, Shnidman, & Maynard, 1992) and for the successful treatment of women with histories of rape or childhood trauma (Poa et aL, 1989; Richards & Rose, 1991: Steketee & Foa, 1987). CBT has also been found helpful with male
combat populations diagnosed with conjoint SUD/PTSD (Perconte-Griger, 1991). Currently, several treatment manuals exist for CBT, including recent manuals for the individual treatment of cocaine use disorder (Beck et aL, 1993) and for PTSD (Foy, 1992).
            Moreover it only has been since recent that the specific issues that dealt with SUD/PTSD in a women’s treatment facility located at (Ground Zero: Urban War Zone) in South Central Los Angeles “Recovering A-NEW” A Culturally Competent Cognitive/Behavioral Treatment Model that directly impacted the recidivism lowering from > 75% to 8.66% with a retention of 8.44% over a six month period. Until this time there had been no CBT manuals address group therapy for women with PTSD and SUD. In planning a group cognitive-behavioral treatment for this population, a strong effort is needed to make CBT accessible and engaging. SUD/PTSD client/clients typically represent a more impaired, treatment-resistant group than SUD-only or PTSD-only client/clients (Brady et aL, 1994). Their clinical presentation, especially early in treatment and while actively using substances' is marked by poor concentration, dissociation, and impulsiveness, which may limit the impact of any traditional verbal therapy. To make CBT most effective for them, several strategies from the educational and cognitive literatures are helpful, all of which have been empirically validated by prior research. These include visual aids (e.g., the use if illustrations, concept-mapping, and charts): role preparation (specific instruction on (he client role, such as ensuring confidentiality and behaving appropriately in group): teaching/or generalization (i.e., promoting the use of CBT techniques outside of therapy sessions through extensive rehearsal, feedback on clients' use of techniques, explicit training in how and when (of use strategies, varying the format and level of difficulty of the materials. and frequent review); emphasis on structured treatment (providing a syllabus outlining the course of treatment sessions, targeting a focal idea for each session to which other concepts are subordinated, providing explicit learning objectives at the  start of each session): testing of acquired knowledge of CBT (a brief written lest at each session, the use of quotations and inspiring descriptions of others with SUD/PTSD who have recovered); and memory enhancement devices (the use of simple language rather than jargon, mnemonic devices, written summaries of main points at each session, and an audiotape for each session to review main ideas) (Najavits & Garber, 1989). Patients are encouraged whenever possible to teach the skills learned in group to others (e.g., a spouse who may help implement use of the strategy) and, at times, to lead the group briefly in a skill they have mastered. be needed to address the generalizability of this treatment model. That is, arc there particular subsets of women with PTSD and SUD who may benefit most or least from the program (e.g., based on age of on-set of each of the disorders, severity of the disorders, clients' access to other concurrent treatments, or clients’ previous treatment histories)? The optimal duration and timing of the treatment, and appropriate aftercare must also be identified.




High Intensity Urban Area
Trauma/Addiction Treatment Model
In South Central Los Angeles
His Sheltering Arms, Inc.
Culturally Immersed Gender Specific
Behavioral Health




Defining the parameters of “Recovering A-New” controlled study

            His Sheltering Arms-HSA provided an environment in South Central Los Angeles where crime and substance use has become a culture of it’s on; this is totally depleting the very fabric of life from the most wonderful citizens that have lived there starting at the end of WWII. Although demographics have changed somewhat that accommodates an ever increasing Latino population that just as most Blacks who had migrated after WWII all are seeking greater social and economic opportunities instead there’s still much gentrification that plagues the area. We look at South of the Santa Monica (10) Freeway to Rosecrans Blvd. and then Alameda Corridor to the East and Western Ave. to the West this defines South Central Los Angeles where the heaviest influence of crime and substance use although there has been in the past several years has decreased it still posses as a major public health concern for young and old. May it be noted that the Alameda Corridor has the greatest re-entry prison population in the country; there are 40,000 low impact prisoners soon to be released in this catchment area alone, this model is designed to affectively inoculate the participants of the “Recovering A-NEW” with treatment, skills and tools for their family members as well  that is premised on safety and productive living by incorporating culturally relevant AUTHENTIC behavior that creates a healthy family and community. 

            The HSA program is the only women’s treatment facility that is licensed by the State of California to accept women directly from the California Department of Corrections (CDC). HSA provides services as well to the Department of Alcohol and Drugs. It house’s and treats women that are pregnant and post partum that already have small children for their disorders; there are women infected with the HIV/AIDS virus, cancer and other chronic problems. This unique campus in the heart of one of the most severely impoverished areas in the city of Los Angeles also has for our seniors an apartment complex and five sober livings that provide safe housing for these women (primarily being women of color) and their small children.

            At no time has there been a model that addressed the co-morbidity on a community-based level that addressed most mental/health care disorders along with these women’s trauma/addiction disorder, i.e. for lack of funds and/or for any other reason.  It is noted that statistic state by the Center of Disease Control-CDC three out of every five women 3:5 have been either sexually or physically abuse in the United States, and two out every five 2:5 men have been abused. In the two groups that were conducted all 26 woman had been either raped multiple times, witness deadly assaults, kidnapped, and have been in very violent and abusive relationships; some of these women coming from prison and/or gang environments. All were tested using the PCL-C trauma indictor and clinically assessed using the criteria set by the DSM IV-TR, diagnosing her trauma related post-traumatic stress disorders AXIS I (PTSD; delayed, chronic; 309.81); with secondary features of Major Depression; 296.30), with Substance Abuse


(Methamphetamine Abuse, 305.70) or (296.20), Alcohol Dependency and (Substance Abuse. 305.00).

            All women were assessed for their level of trauma and addiction problems on one-on-one session that were conducted by the clinical consultant a psychologist that has retired from working for the Department of Veterans Affairs at the Veterans Resource Center that specializes in combat/sexual trauma for military personnel for 11 years retired. The two Trauma/Addiction groups simultaneous addressed both morbidities. The only other  treatment facilities that implement these treatment protocols is in the Department of Veterans Affairs Menlo Park, California VA Hospital and some Vet Centers ran by the Veterans Administration.

1 In Menlo Park California at the National Center for the Education and Treatment of Post Traumatic Stress Disorder, at the Veterans Administration Hospital. Studies are in the fifth year addressing the comorbidity of Substance Abuse and PTSD. The Seeking Safety Model by Dr. Lisa Najavitis, Ph.D. at Harvard School of Psychiatry, has the model in place and is being conducted by Robin Walser, Ph.D. at the center on two populations, Vietnam combat veterans and sexual assault women veterans .the model is an integrated one that addresses the comorbidity of substance abuse and PTSD in concert of one another.

2  25-75% of survivors of abusive or violent trauma report problematic alcohol use. 10% - 33%  of survivors of accidental, illness, or disaster trauma report problematic alcohol use, especially if troubled by persistent health problems or pain. Being diagnosed with PTSD increases the risk of developing an alcohol use disorder. 60-80% of Vietnam veterans seeking PTSD  treatment have alcohol use disorders.


The “Recovering A-NEW” Group Study: PTSD/Addiction Treatment Groups

Group # 1 Baseline N= 13 participants

Group #2 Baseline N= 13 participants

Age of Women 19 -52
Mean age 35.5

90 – 180 Days

90 – 180 Days

HSA women all participated in no less than 16 session translating into 32 therapeutic hours.

Two (2) women were referred from program before completion

One (1) left program before completion

Program had >75 % recidivism 

After 90 days average group size N=9

After 90 days average group size N=9

Programs recidivism dropped to 8.66% and Retention 91.44%

Three (3) women gave birth during participation

Two (2) pregnant




Four (4) participants discontinued all use of psychotropic medication

Two (2) participants discontinued all use of psychotropic medication





180 Days Grp. participation average group size N=9

180 Days Grp. participation average group size N=9

Programs recidivism dropped to 8.66% and Retention 91.44%

Total certifications for successfully completing Trauma/Addiction Grp. N=10

Total certifications for successfully completing Trauma/Addiction Grp. N=7

Certification for given for successfully completing N=17
Total N=26




Copyright 2010 Dr. Ronald Beavers All Rights Reserved